MEDICARE: MARILYN KIESTER MS, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	6638	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1391A	OTHER	NC	NC BCBS

General Provider Information

NPI Number	:	1376537332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN KIESTER MS, CCC-SLP

Provider Business Mailing Address
First Line	:	16420 WOOLWINE RD.
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28270
Country	:	US
Telephone Number	:	704-953-9653
Fax Number	:	704-587-9531

Provider Business Practice Location Address
First Line	:	6924 NEEDHAM DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-2837
Country	:	US
Telephone Number	:	704-607-0014
Fax Number	:	704-442-8724

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/09/2007

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